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Spinal Cord Injury in Children

By

Gordon Mao

, MD, Johns Hopkins School of Medicine

Last full review/revision Sep 2021| Content last modified Sep 2021
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Although children < 10 years have the lowest rate of spinal cord injuries, such injuries are not rare. Most spinal injuries in children occur in the neck.

In children < 8 years, cervical spine injuries occur most commonly above C4 and are most commonly caused by motor vehicle crashes, falls, and child abuse. In children > 8 years, injuries at C5 to C8 are more common and are due to motor vehicle crashes and sports injuries, particularly gymnastics, diving, horseback riding, American football, and wrestling. Compared with adults, children have distinct anatomic features (eg, larger head size-to-body, elasticity of spinal ligament capsules) that predispose them to hypermobility of the spinal column without apparent bony injury.

Children with spinal cord injury may have transient symptoms such as paresthesias and weakness. Children may also have lancinating pains down the spine or extremities. In about 25% of affected children, onset of neurologic signs (such as partial neurologic deficits, complete paralysis) is delayed from 30 minutes to 4 days after injury, making immediate diagnosis difficult.

Spinal cord injury without evidence of radiologic abnormality (SCIWORA) is related to direct spinal cord traction, spinal cord impingement, spinal cord concussion, and vascular injury. This type of injury occurs almost exclusively in children and often occurs in the cervical spine. In spinal cord injury without evidence of radiologic abnormality, the patient has neurologic findings suggestive of spinal cord injury (eg, paresthesias, weakness) but normal anatomic alignment, and no bone abnormalities are seen on imaging studies (plain x-rays, CT, and/or MRI).

Children immobilized by SCIWORA or other spinal cord injuries are at risk for complications due to immobility, including decubitus ulcers Pressure Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more Pressure Injuries , thromboembolic complications, atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more Atelectasis and pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more , hypertensive autonomic dysreflexia, and complications due to neurogenic bladder Symptoms and Signs Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by neurologic damage. Symptoms can include overflow incontinence, frequency, urgency, urge incontinence, and retention.... read more , including lower or upper urinary tract infection Introduction to Urinary Tract Infections (UTIs) Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys (pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra... read more (secondary to a chronic indwelling catheter), ureteral calculi Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more , vesicourethral reflux Vesicoureteral Reflux (VUR) Vesicoureteral reflux is retrograde passage of urine from the bladder back into the ureter and sometimes also into the renal collecting system, depending on severity. Reflux predisposes to urinary... read more , and ultimately chronic kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is long-standing, progressive deterioration of renal function. Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia... read more Chronic Kidney Disease .

Diagnosis

  • X-rays (cross-table lateral view, anteroposterior view, and open-mouth odontoid view)

  • Usually CT, particularly for bony or ligamentous injury

  • MRI to confirm injury site and level within the spinal cord

Spinal cord injury should be suspected in any child who has been in a motor vehicle crash, has fallen from a height 3 meters, or has had a submersion injury.

Spinal cord injury without evidence of radiologic abnormality (SCIWORA) is suspected in children who have even transient symptoms of neurologic dysfunction or lancinating pains down the spine or extremities and a mechanism of injury compatible with spinal cord injury. SCIWORA is a common phenomenon originally described in the 1980s, when there was a lack of MRI scanners capable of detecting the causative radiologic abnormalities. The term SCIWORA is less commonly used currently because MRI scanners are more readily available in hospitals in the US and can identify the causative radiologic abnormalities.

Depending on local imaging resource availability, imaging usually begins with x-rays, including cross-table lateral, anteroposterior, and open-mouth odontoid views. If fracture, dislocation, or subluxation is suspected based on x-ray findings or a very high-risk mechanism of injury, CT is usually done. MRI is usually done with any of the following:

  • Spinal cord injury is suspected based on x-ray or CT

  • Spinal cord injury is suggested by neurologic deficits on examination

  • Spinal cord injury is suggested by a history of even transient neurologic deficits

Treatment

  • Immobilization

  • Maintenance of oxygenation and spinal cord perfusion

  • Supportive care

  • Surgical stabilization when appropriate

  • Long-term symptomatic care and rehabilitation

Children with a spinal injury should be transferred to a pediatric trauma center.

Acute treatment is similar to treatment in adults Treatment Trauma to the spine may cause injuries involving the spinal cord, vertebrae, or both. Occasionally, the spinal nerves are affected. The anatomy of the spinal column is reviewed elsewhere. Spinal... read more Treatment , with immobilization and attention to the adequacy of oxygenation, ventilation, and circulation. Surgical stabilization is less frequently indicated in children than adults with spinal cord injury; because spinal ligaments tend to be more lax in spinal cord injury without evidence of radiologic abnormality (SCIWORA) and bone fractures and complete ligamentous avulsion are absent, there may be no suitable target structure for stabilization. Another advantage of bracing is preservation of spinal mobility by avoidance of fusion surgery; fusion surgery increases risk of long-term spondylosis Cervical Spondylosis and Spondylotic Cervical Myelopathy Cervical spondylosis is osteoarthritis of the cervical spine causing stenosis of the canal and sometimes cervical myelopathy due to encroachment of bony osteoarthritic growths (osteophytes)... read more . Historically, high-dose corticosteroids have been used at various dosing schedules and regimens, but multiple clinical trials in adults have failed to demonstrate any added clinical benefit but have shown increased risk of wound infection, pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more Pulmonary Embolism (PE) , sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more , and death. Thus, for children with spinal cord injury, centers in the US tend to avoid long-term use of corticosteroids, although some clinicians use short courses of high-dose steroids in the perioperative setting only.

Long-term treatments for pediatric SCIWORA are similar to treatments for adult spinal cord injury, with focus on both intensive physical rehabilitation of neurologically affected extremities and medical support for various common medical complications that occur with prolonged immobilization or weakness. Rehabilitation is multidisciplinary with involvement of physical therapists for gait training and lower extremity strengthening, occupational therapists for cervical cord injuries affecting upper extremity motor function that can result in contractures, and even speech therapists to assist with swallowing and secretion-clearance issues that affect high cervical injuries. Regular medical care and visits are necessary for severe spinal cord injury patients who are nonambulatory due to high risks of developing complications resulting from immobility.

Prognosis is directly related to initial neurologic function after injury. Children achieve better neurologic outcomes than adult patients with spinal cord injury (1, 2 Treatment references Although children 8 years, injuries at C5 to C8 are more common and are due to motor vehicle crashes and sports injuries, particularly gymnastics, diving, horseback riding, American football... read more ).

Treatment references

  • 1. Pang D, Pollack IF: Spinal cord injury without radiographic abnormality in children—the SCIWORA syndrome. J Trauma 29: 654–664, 1989. doi: 10.1097/00005373-198905000-00021

  • 2. Wang MY, Hoh DJ, Leary SP, et al: High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine 29:1493–1497, 2004. doi: 10.1097/01.BRS.0000129026.03194.0

Key Points

  • Most spinal injuries in children involve the neck.

  • Neurologic symptoms and signs may be delayed from 30 minutes to 4 days after injury in about 25% of affected children.

  • Children may have spinal cord injury without evidence of radiologic abnormality (SCIWORA).

  • SCIWORA should be suspected with even transient symptoms of neurologic dysfunction or lancinating pains down the spine or extremities.

  • Do MRI in all patients who had neurologic symptoms, neurologic deficits on examination, or spinal injury detected on other imaging studies.

  • Surgical stabilization is less frequently indicated in children than adults with spinal cord injury.

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